Most people are now covered by some form of public or private medical insurance and a substantial portion of all medical fees are paid through such insurance. In the context of the patient and the physician or any other health care provider relationship, it is the typical procedure for the provider to bill the patient for the full cost of the service with the patient or service provider then filing a claim with his insurance carrier for reimbursement of part or all of the service fee. The routine processing of an insurance form can take many weeks and it can be a substantial time before the patient or medical service provider receives a reimbursement for the medical expense. In most cases, the insurance claim forms are complex and difficult for both patients and medical providers to understand. There is a substantial likelihood that mistakes can be made in the preparation of the forms. When such mistakes are made, there is a still further delay in the processing of the claim for payment to the patient or health care provider.
For many patients it is financially difficult to make a fee payment to the service provider prior to receiving payment from the insurance carrier but the service provider desires to receive his payment on a prompt basis. Therefore, the difficulty in filing and reimbursement of insurance claims serves to work a hardship for both the health care provider and the patient.
Many insurance companies include a provision in their claim form for the assignment of the insurance claim payment from the patient to the service provider. An intent of this assignment is to relieve the patient of the immediate burden of that portion of the service provider's fee which will be reimbursed by insurance. In practice, however, the assignment provision of insurance claims has proven to be of limited benefit to either the patient or medical service provider, since many service providers demand some immediate form of payment at time of service. At present, there exists no simple system or method whereby either a patient or health care provider has instant accessibility to a multitude of insurance claim payment schedules for medical services. It is difficult, therefore, for patients and/or health care providers to make an assignment decision on an insurance claim payment because the insurance claim payment information is not readily available to both parties involved in the insurance claim assignment provision.
Insurance carriers develop fee payment schedules which determine the fee that they will pay for each particular type of service. These tables are generally complex and involve hundreds of items with the fee payment for each item dependent upon several factors such as deductibles, accident only exclusions and time related factors which affect reimbursement to both patients and health care providers. With the exception of government managed insurance programs, fee payment schedules are not made easily available to patients or health care providers. However, these fee payment schedules are available. Thus, when a health care provider renders a service to a patient and a claim form is prepared, the health care provider may be, or is often reluctant to accept the claim assignment provision of the insurance payment since in most cases neither the physician nor the patient knows the amount that the insurance carrier will pay for the service. As a result, a health care provider cannot determine the differential, if any, between the insurance payment and his fee charge to determine how much to bill the patient. As a result of this lack of knowledge, some or most health care providers are often unwilling to agree to the assignment provision of an insurance claim. This, in turn, works a hardship for patients who are asked by health care provider's to pay for their services rendered at the time of service. Low income patients and elderly patients on fixed incomes particularly are affected when they must pay the full service fee. If the health care provider or patient agrees to the assignment provision, the provider must await the slow processing of the insurance forms and the preparation of a payment check which the provider must first receive before he can determine if there is any additional billing to be made to the patient.
In view of the above problems relating to the assignment provision of insurance claims and the difficulties in processing insurance claim forms, there exists a need for a method of rapidly determining the reimbursement of an insurance company's claim amount which will be paid by a specific insurance carrier to a patient or a health care provider for a particular service. This amount should be determined while the patient is still present in the service provider's office. If the health care provider and the patient could be given a method by which either party is able to determine the amount of the insurance claim reimbursement for a particular service, either party, i.e., the doctor or patient can make a better reasoned business decision to facilitate agreement to the insurance assignment provision. As a result, the patient will have a substantially reduced immediate payment for the service, or possibly no payment at all. Although the insurance assignment and claim processing problems are particularly relevant to the physician-patient relationship, these problems are also present in other health care areas such as hospitals, clinical laboratories, supplying of durable medical equipment (DME) and nursing homes.
As health care costs for hospital and medical service provider related services continue to rise under both private and government-managed health insurance plans, "cost containment" in the health care field becomes a problem that our society must address.
One method by which both private and government-sponsored insurance plans are currently dealing with "cost containment" is requesting that their subscribers receive cost amount "bids" or "claim payment amounts" for medical treatments or services from different health care providers i.e. doctors, hospitals, or medical suppliers, before certain services or treatments are rendered.
A cost-control mechanism is therefore needed to help with "cost containment" in the health care field, without, of course, destroying the needs under the free enterprise system or the private relationship which must be maintained between insurance carriers, patients and various health care providers.
There is a need for greater interaction and dissemination of medical cost information to all parties involved in the present health care field for supporting cost containment measures. The greater dissemination of health care information for cost control serves the benefit of:
(1) Patients PA0 (2) Health care providers (doctors, laboratories, etc.) PA0 (3) Insurance carriers PA0 (4) Hospitals
without destroying any existing "freedom of choice" relationships which exist under our present system of health care management.
There also exists a lack of knowledge and understanding by both patients and medical health care providers as to the validity and provisions or limits of coverage of medical benefits under a certain particular insurance carrier's policy.
Because of this lack of knowledge and the complexities of whether or not a particular insurance policy is valid or current, and because of the ever-changing regulations by both private and government managed medical insurance plans, there exists a need for a method by which both health care provider, i.e., hospital, doctor, etc., and the patient can be rapidly informed as to the validity of coverage and benefits under one or more of the patient's health care insurance plans.